Journal Article > Study

Vital signs remain a mainstay of monitoring for deterioration, and early identification of and rapid response to clinical deterioration is critical to preventing patient harm. This observational study used an automated technique to characterize vital sign measurement for nearly 50,000 intensive care unit stays. Investigators found that omission of vital sign recording occurred more than one third of the time. The analysis identified logically inconsistent blood pressure measurements, which suggested data-entry error. The data included a significant proportion of unusual, outlier vital sign values. Taken together, these results demonstrate important inaccuracy in vital sign documentation in the intensive care unit. The authors recommend seeking alternatives to hourly vital sign monitoring in order to optimize safety. A previous WebM&M commmentary discussed challenges in monitoring vital signs.

The recent death of comedienne Joan Rivers, which followed a cardiac arrest during a routine throat procedure, has brought national attention to the potential safety hazards of office-based procedural anesthesia. This retrospective study examined adverse events associated with moderate procedural sedation performed outside of the operating room at a tertiary medical center. Adverse events were relatively rare, with only 52 safety incidents identified out of more than 140,000 cases over an 8-year period. The most common harm was oversedation leading to apnea and requiring the use of reversal agents or prolonged bag-mask ventilation. Women were found to be at particularly increased risk for adverse events including oversedation and hypotension. These findings suggest that a combination of patient and procedural characteristics may help risk stratify patients, allowing for appropriate responses such as increased monitoring and staffing for patients likely to experience sedation-related complications. A previous AHRQ WebM&M perspective described office-based anesthesia as the "Wild West" of patient safety.

Accurately detecting safety events remains challenging, and health care organizations are still struggling to determine the incidence of adverse outcomes associated with nursing care. This study used chart reviews to identify the rates of six adverse events considered to be directly related to nursing care: pressure sores, falls, medication administration errors, pneumonia, urinary infections, and inappropriate use of restraints. One in seven hospitalized adults experienced at least one of these adverse events.

Cases & Commentaries

Presenting with jaundice and epigastric pain, a woman with a history of multiple malignancies was admitted directly for an ultrasound-guided liver biopsy. After the procedure, the patient had low blood pressure and complained of new abdominal pain, which worsened over the next 2 hours. The bedside nurse soon found the patient unresponsive.

Journal Article > Study

Basic nursing care, such as measuring and recording vital signs, is often left undone. This qualitative study found that nurses frequently fail to accurately record patients' respiratory rates due to more urgent work tasks, confirming findings from prior studies.

Book/Report

This publication presents findings from an investigation, prompted by reports of alarm fatigue, which identified gaps in training and competencies of nurses in 29 Veterans Health Administration facilities.

The obesity epidemic is considered an urgent public health issue in Europe and the United States. Although morbidly obese patients are prone to a variety of medical issues, no study to date has evaluated patient safety risks in this population. This retrospective analysis of errors voluntarily reported to the United Kingdom's National Patient Safety Agency documents more than 380 errors and near misses in which obesity was considered a contributing factor. The majority of errors were partly attributable to inadequate equipment for caring for such patients, particularly in the surgical and critical care environments. Based on these data, the authors advocate for multidisciplinary approaches to systematizing care for morbidly obese patients. The challenges of caring for obese patients are discussed in an AHRQ WebM&M commentary, which examined a case of an ultimately fatal delayed diagnosis in a morbidly obese woman.

Journal Article > Study

Patient safety in trauma poses unique challenges given the acuity of the patients and the need for rapid assessment in delivering life-saving care. This study analyzed more than 2500 complications discussed at morbidity and mortality (M&M) conferences to characterize their preventability and clinical relevance. Investigators discovered that the complications ripe for quality improvement initiatives included unintended extubations, surgical technical failures, missed injuries, and intravascular catheter-related complications. An invited critique [see link below] reflects on the study's findings and points out the challenges in reporting performance data without needed standardization. A past AHRQ WebM&M commentary discussed the systematic assessment of trauma patients in the context of a missed patient injury.

Journal Article > Study

The authors present a case study of accidental intravenous breast milk administration to a premature infant. They discuss using both root cause analysis and a professional network to illustrate the value of finding systemic contributions to rare but potentially dangerous mistakes.